Healthcare Provider Details

I. General information

NPI: 1407302847
Provider Name (Legal Business Name): ELIA BOLES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2016
Last Update Date: 08/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CARILION CLINIC ROANOKE MEMORIAL HOSPITAL 1906 BELLEVIEW AVE,
ROANOKE VA
24014
US

IV. Provider business mailing address

6736 MALLARD LAKE DR
ROANOKE VA
24018-6931
US

V. Phone/Fax

Practice location:
  • Phone: 540-981-7000
  • Fax:
Mailing address:
  • Phone: 540-855-1169
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0116029797
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: